Management of Postherniorrhaphy Chronic Neuropathic Groin Pain: A Role for Dorsal Root Ganglion Stimulation

Abstract

Chronic neuropathic groin pain is a sequela of hernia surgery that occurs at unacceptably high rates, causing widespread impacts on quality of life. Although the medical community is beginning to recognize the role of surgical technique in the initiation and maintenance of postherniorrhaphy neuropathic pain, little information exists regarding pain management strategies for this condition. This review presents a summary of the pain condition state, its treatment options, and treatment recommendations. Both literature review and clinical experience were used to develop a proposed a treatment algorithm for the treatment of postherniorrhaphy pain. The development of chronic pain may be prevented via a number of perioperative measures. For pain that is already established, some surgical approaches including inguinal neurectomy can be effective, in addition to standard pharmacological treatments and local infiltrations. An unmet need may still exist with these options, however, leaving a role for neuromodulation for the treatment of intractable cases. A pain management algorithm for iterative interventions including stimulation of the dorsal root ganglion (DRG) is described. It is expected that cross-disciplinary awareness of surgeons for nonsurgical pain management options in the treatment of chronic neuropathic postherniorrhaphy pain will contribute to better clinical outcomes.

Effectiveness and Safety of Dorsal Root Ganglion Stimulation for the Treatment of Chronic Pain: A Pooled Analysis

“…DRG neurostimulation has been shown to effectively treat discrete areas of pain, such as the groin and foot, which are typically more difficult to treat with traditional SCS without causing discomfort in non‐painful regions . In these specific areas, our pooled analysis showed an 80% responder rate at one year.…”

Spinal Cord Stimulation: Clinical Efficacy and Potential Mechanisms

“…Technical barriers relating to placing the leads adjacent to the DRG were overcome though development of a specifically designed lead delivery system. Initial studies, which have been encouraging, showed sustained pain relief in patients with focal neuropathic pain, such as CRPS and groin pain, which are traditionally difficult to treat with conventional SCS . In a recent prospective RCT, which led to U.S. Food and Drug Administration approval, Deer et al .…”

“…Initial studies, which have been encouraging, showed sustained pain relief in patients with focal neuropathic pain, such as CRPS and groin pain, which are traditionally difficult to treat with conventional SCS. [166][167][168][169][170] In a recent prospective RCT, which led to U.S. Food and Drug Administration approval, Deer et al 12 demonstrated that in patients with CRPS, DRG stimulation was superior to conventional SCS for the primary composite outcome (≥ 50% reduction in VAS score from baseline for the trial and at 3 months after implantation; lack of neurologic deficits) and for secondary end points, including positional effects on paresthesia, quality of life, emotional scales, satisfaction, stimulation specificity, and percent change. The study is remarkable in that 81.2% of patients randomized to DRG SCS achieved success at 3 months, compared with 55.7% in those who received conventional stimulation, and these results were stable at 12 months.…”

Neuromodulative Schmerztherapie

“…Die Dorsalganglienstimulation ist eine wichtige Neue rung, mit der es erstmals möglich ist, kleine, abgeschlos sene Schmerzareale wie beispielsweise Knie oder Leisten schmerzen gezielt zu behandeln. Obwohl diese Stimula tionsform erst seit wenigen Jahren zur Verfügung steht, gibt es hierzu eine große Anzahl von Studien und Lang zeitergebnissen [29][30][31][32][33][34]. In einer Studie mit 62 Patien ten konnte gezeigt werden, dass über einen Zeitraum von 3 Jahren eine sehr gute Schmerzlinderung von mehr als 50 % erreicht werden konnte (p < 0,0001) [30].…”